d/or Parent/Legal Guardian of Minor: First Name: Kamm Last Name: Shuliak Birth Date: State: Address: City: Postal Code: 10065 Email: Phone: Legal Signature of Adult Participant or Parent/Guardian if a minor participant(s): EFTA00522226 Date and rime Signed: 10/08/2017 at 10:24 System Time Stamp: 10/08/2017 at 2:20 EFTA0